The Denver Developmental Screening test has shown a 6-month-old is delayed in gross motor development. Activities by the nurse aimed at helping the child attain appropriate developmental levels would include which of the following?
1. Encouraging the child to stand
2. Talking to the child and playing music
3. Pulling the child to a sitting position and propping the child in a sitting position
4. Encouraging the child to hold a rattle or playing patty-cake
3. Pulling the child to a sitting position and propping the child in a sitting position
Rationale:
The infant at 6 months should have head control and is working on sitting without support. Pulling the child to a sitting position allows the neck muscles to support the head. Propping the child in a sitting position helps to develop self-righting behaviors. It is too early to worry about standing. Talking to the child promotes language development, not gross motor development. Handling a rattle is fine-motor behavior, not gross motor behavior.
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Which of the following should be used when suctioning a mechanically ventilated patient? (Select all that apply.)
a. Three hyperoxygenation breaths (breaths at 100% FiO2) b. Hyperinflation (breaths at 150% tidal volume) c. Limit the number of passes to three. d. Instill 5 to 10 mL of normal saline to facilitate secretion removal. e. Use intermittent suction to avoid damaging tracheal tissue.
The nurse is preparing a preoperative plan of care for an older Hispanic client who is scheduled for a hysterectomy. The nurse recognizes the initial intervention for this client will be to:
1. Determine if the client understands English. If not, provide an interpreter. 2. Teach the client about turn, cough, and deep breathing. 3. Discuss the client's concerns about the surgery. 4. Explain that the client's pain will be controlled during the postoperative time frame.
As a nurse manager, you trial a new pain scale on your unit that is supported by numerous research studies. You compare the patient outcomes with the new scale against the existing scale
Feedback from staff suggests that the new scale is too difficult for patients who have limited language skills and who are already under duress to understand. The difficulty in implementing the new scale refers to testing: a. Efficacy. b. Effectiveness. c. Practice failure. d. Comparative error.
The nurse is administering analgesic medication to a group of clients. Which of the following is most correct regarding the ethical issues in pain management?
1. Pain should be managed to improve the patient's quality of life. 2. Opiates are not recommended for patients with addiction issues. 3. Patients with psychiatric diseases should avoid opiates for malignant pain. 4. The nurse should be certain pain is present prior to administering opiates.